|Year : 2022 | Volume
| Issue : 1 | Page : 2-9
Leaks after sleeve gastrectomy – A narrative review
Nikhil Jain1, Rajesh Bhojwani2, Kamal Mahawar3
1 Department of Surgery, Apollo Hospital, Muscat, Sultanate of Oman
2 Department of Surgical Gastroenterology and Minimal Invasive Surgery, Santokba Durlabhji Memorial Hospital Cum Medical Research Institute, Jaipur, Rajasthan, India
3 Department of Surgery, Sunderland Royal Hospital, University of Sunderland, Sunderland, United Kingdom
|Date of Submission||28-Sep-2021|
|Date of Acceptance||21-Dec-2021|
|Date of Web Publication||09-Mar-2022|
Dr. Rajesh Bhojwani
Department of Surgical Gastroenterology and Minimal Invasive Surgery, Santokba Durlabhji Memorial Hospital Cum Medical Research Institute, 3rd Floor, IPD Building, Bhawani Singh Marg., Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic sleeve gastrectomy has become a standalone procedure for the treatment of severe obesity with excellent short- and mid-term outcome. Staple-line leak is one of the most dreaded complications of this procedure. Following a standardized sequence of critical steps can help decrease the incidence of leaks. In this review, we examine the etiopathogenesis of leaks after laparoscopic sleeve gastrectomy and important implicated technical considerations. Materials and Methods: A comprehensive literature search of various databases was performed with relevant keywords. The published scientific literature was critically appraised. Results: Patient-, surgery-, and surgeon-related risk factors should be recognized and modifiable risk factors should be addressed. There are anatomical, physiological, and technical considerations that contribute to the pathogenesis of leaks, based on which a multitude of precautions need to be taken to prevent staple-line leak. Conclusion: The correct bougie size, distance from the pylorus, stapler size, orientation of staple line, and distance from angle of His and an intraoperative leak test are some of the crucial aspects for a successful outcome after sleeve gastrectomy. Staple size less than that of 1.5 mm should not be used on the stomach, stapling should be initiated at least 5 cm from pylorus and calibrated on a bougie that should not be <32 Fr size. Reinforcing the staple line reduces the incidence of hemorrhage, and current evidence indicates the incidence of leak. Performing a leak test, though offers less sensitivity to predict a leak, does help in detecting the immediate mechanical failure of staple line.
Keywords: Bariatric surgery, laparoscopic sleeve gastrectomy, laparoscopic surgery, morbid obesity, staple-line leak
|How to cite this article:|
Jain N, Bhojwani R, Mahawar K. Leaks after sleeve gastrectomy – A narrative review. J Bariatr Surg 2022;1:2-9
| Introduction|| |
Laparoscopic sleeve gastrectomy (LSG), first described by Michel Gagner as a part of a two-stage duodenal switch operation (DS), is now the most common bariatric procedure with short- and mid-term excess weight loss (EWL) and resolution of comorbidities comparable to the roux-en-Y gastric bypass (RYGB) and a superior reoperation and procedure-related morbidity rates. Technical ease, avoidance of an implant or adjustments, absence of an enteric anastomosis, and a shortened operating time with excellent safety outcomes are some of the factors behind its meteoric rise. At the same time, this procedure is not without its own problems. Leak from staple line is a potentially catastrophic complication which can result in significant morbidity and even mortality. In this review, we examine the published scientific literature to understand the etiopathogenesis of this unique clinicopathological entity and recognize the technical subtleties to accomplish a safe and successful sleeve gastrectomy.
| Materials and Methods|| |
A comprehensive literature search was performed through the following databases: PubMed, Embase, Scopus, Cochrane database of systematic reviews, and Google Scholar with the search terms: “bariatric surgery,” “sleeve gastrectomy,” “laparoscopic sleeve gastrectomy,” “leaks,” and “staple line leaks.” A further search of the bibliography of each article for additional articles that may have been missed during the original search was also done. Inclusion criteria included systematic reviews, narrative reviews, meta-analysis, and original articles. Duplicates, letter to editor, and case reports were excluded from the study.
| Results|| |
Multiple factors contribute to the etiopathogenesis of leaks after sleeve gastrectomy. Patient-related, surgery-related, and surgeon-related risk factors should be recognized and modifiable risk factors should be addressed [Table 1]. There are anatomical, physiological, and technical considerations that contribute to the pathogenesis of leaks, based on which a multitude of precautions need to be taken to prevent staple-line leak. Based on tissue thickness, a staple size less than 1.5 mm should not be used on the stomach. To balance the risk of postoperative stricture or leak and concomitantly allowing for an acceptable weight loss, stapling should be initiated at least 5 cm from pylorus and calibrated on a bougie that should not be <32 Fr size. Reinforcing the staple line definitely reduces the incidence of hemorrhage, and current evidence indicates the incidence of leak also [Table 2]. Performing a leak test, though offers less sensitivity to predict a leak, does help in detecting the immediate mechanical failure of staple line.
|Table 1: Risk factors for staple-line leak after laparoscopic sleeve gastrectomy|
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|Table 2: Studies comparing different methods of staple-line reinforcement|
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| Discussion|| |
Sleeve gastrectomy may be seen as an extension of the Magenstrasse and Mill procedure, with the first open sleeve gastrectomy performed by Doug Hess in 1998 followed 2 years later by the first laparoscopic sleeve gastrectomy by Gagner et al. as part of a DS procedure, they subsequently also reported sleeve gastrectomy after biliopancreatic diversion with DS as a salvage procedure for poor weight loss. Regan et al. reported sleeve gastrectomy as a first step for sufficient weight loss prior to performing a more definite procedure such as RYGB or DS in high-risk patients with obesity to decrease mortality and morbidity. LSG has been associated with excess body mass index (BMI) loss of 72.3% at 1 year and 61.1% at 5 years. A systematic review and meta-analysis of comparative studies evaluating outcomes between LSG and RYGB showed that mid-term weight loss was comparable between these two procedures, and a sustained resolution of comorbidities, including type 2 diabetes mellitus, hypertension, hyperlipidemia, and hypertriglyceridemia, was evident in long-term follow-up. The efficacy of LSG is further evident from a recently published systematic review and meta-analysis of randomized control trials (RCTs) which demonstrated that both RYGB and LSG result in sustained weight loss and comorbidity control at 5 years.
Risk factors for leak
A number of risk factors have been identified which can be patient related, surgery related, or surgeon related [Table 1].
The modifiable patient-related factors include smoking, alcohol consumption, and use of nonsteroidal anti-inflammatory drugs (NSAID) and antacids. The other factors include male gender, a higher preoperative BMI, and presence of sleep apnea. For a surgical patient, smoking is a major cause of microvascular disease leading to tissue ischemia and a significantly increased incidence of organ space infection in the bariatric population, as demonstrated in a large cohort study. The use of antacids is associated with reflux disease and indirectly with higher intragastric pressure, thus a higher incidence of leaks. A German multicentric observational study involving 5400 patients reported an association of male gender, BMI between 50 and 59.9 kg/m2, concomitant sleep apnea, conversion to laparotomy, and a longer operation time with a significantly higher leakage rate.
Preoperative and intraoperative factors have been identified which have a bearing on the final outcome after LSG. Hypotension preoperatively and intraoperatively has been shown to be associated with staple-line leak. Preoperatively, hypotension is caused by induction agents and associated hypovolemia and intraoperatively by using maintenance agents in the form of volatile or intravenous anaesthetics. In 2005, Monk et al. reported that intraoperative hypotension (IOH) was independently associated with 1-year mortality. A French survey on anesthesia-related mortality reported that IOH was related to myocardial ischemia. In a multivariate analysis, intraoperative systolic pressure <100 mm Hg for 20 min remained a significant factor for the occurrence of leaks.
Intraoperative contributing factors include staple-line bleeding, increased intraluminal pressure, technical failure of stapling device, distance from the pylorus, and the size of bougie used for calibration. Staple-line bleeding is considered a direct predisposing factor for leakage after LSG as hematomas over the suture line affect its vascularity and vitality. Modifiable factors predisposing to bleeding include smoking, alcohol consumption, NSAID use, metabolic factors such as liver disease (including nonalcoholic fatty liver), coagulopathy, hypertension, and super-obesity. The resection of a sleeve from the stomach transforms it into a smaller tube with a high intraluminal pressure. In a meta-analysis, the bougie size was found to be inversely related to the complication risk without impacting EWL up to 3 years. A distance of <2 cm from the pylorus was shown to be significantly related to a higher incidence of fistula.
Finally, as with all major laparoscopic procedures, the surgeon's experience is related to the decreased risk of staple-line leak. The role of the learning curve, associated with increased hospital caseload, seems to have an impact on the gastric leak rate which was shown in a study by Stroh et al. Based on 11,800 patients, it was seen that the yearly leak rate dropped from 6.5% to 0.9% during a 6-year period (overall leak rate: 1.5%), while the number of sleeve gastrectomy cases increased dramatically (154 cases in 2007–3285 in 2013). Another example is the study from Noel et al., who, on a retrospective analysis of a single surgeon's experience, showed the yearly leak rate dropping from 4.7% to 0% over 8 years.
The transformation of the stomach into a tubularised sleeve alters the physiological and anatomical properties such that a distinct biomechanical system is created. The interplay of these associated intrinsic anatomical, physiological, and technical factors results in two basic etiopathological aspects leading to leaks – mechanical and ischemic. Based on the sequential events that occur in these two different etiologies, mechanical leaks usually appear within 48–72 h after surgery and ischemic leaks occur 5–7 days after surgery when the wound healing is between the inflammatory and fibrosis phases. Mechanical leaks occur due to a technical failure when forming the staple line as a result of faulty instruments or technique which manifests early in the postoperative period. In contrast, ischemic leaks result due to a complex and tenacious blood supply of the stomach which renders particular segments vulnerable to postoperative vascular insufficiency leading to staple-line failure. The pathogenesis of staple-line leaks can be divided into anatomical, physiological, and technical considerations.
Fundus and corpus, surgically removed as a part of the LSG, are the most expandable portion of the stomach and serve an important reservoir function., The resultant sleeve has a volume that is <10% of the volume of the whole stomach with a higher mean pressure (43 ± 8 mmHg vs 34 ± 6 mmHg, P < 0.005). The remaining anatomical parts of the stomach, namely the proximal cardia and the distal pylorus, function as a valve contributing to an increased intraluminal pressure in the remnant sleeve. Further, in the region of the incisura angularis, the narrowing of the sleeve can lead to stricture that may act as a distal obstruction.
Following LSG, the neostomach thus created has an altered physiology based on biophysical and biomechanical properties. There are changes in the intragastric pressure, vascularity, and the wall thickness of the stomach. Intragastric pressure has been shown to increase with coughing to as high as 233 mmHg (mean = 37 mmHg) and with vomiting to as high as 290 mmHg (mean = 81 mmHg). This pressure is amplified by the fact that the compliance of the sleeve is ten times less than that of the complete stomach or the resected fundus., The mechanical effect of increased intra-sleeve pressure also affects the microcirculation.
The most pertinent pathophysiological factor is the occurrence of regional ischemia of the staple line which may predispose to leakage even weeks after the surgery. The vascular supply of the stomach, which predominantly arises from the left and right gastric arteries and the left and right gastroepiploic arteries, is often unequal in size and location. The left gastric artery (LGA) forms an inverted U in the lesser omentum and supplies the lesser curvature. At the superior end of its course, the left gastric artery gives off an inconsistent cardio tuberosity branch for the cardia of the stomach before dividing into the anterior and posterior terminal branches. The splenic artery along with the short gastric arteries and left gastro-epiploic artery that connects to its right counterpart forms the arterial circle of the greater curvature. The splenic artery also participates in vascularization of the posterior gastric wall with the posterior gastric artery, which is not always present. Perez et al., in a detailed anatomical study, demonstrated that the vascular supply of the upper part of the gastric tube can be damaged by a sleeve gastrectomy procedure if one of the three branches arising from the LGA is severed. When one or two branches are cut, submucous plexus allows replacement of blood flow, but when three are stapled, the anastomosis system is not sufficient and a weak area is created. Saber et al. provided a radiological evidence of this precarious blood supply by measuring the perfusion index of the gastric mucosa using computed tomography perfusion scanning. This study showed that the gastric wall perfusion is significantly decreased at the angle of His (AOH) and gastric fundus compared with perfusion at other gastric points. Further, it was demonstrated that patients suffering from obesity showed a diffused diminished blood supply which was statistically significant at the fundus. Thus, the stomach at the AOH and fundus has a tenuous blood supply leading to leak at the proximal third of the staple line in up to 90% of cases.
The consistent site of post-LSG leaks near the gastroesophageal junction (GE junction) has swerved the focus of research toward the structural elements, i. e., the gastric wall in a bid to understand its role in the causation of leaks. Three studies have measured wall thicknesses of the dissected stomach after LSG.,, The wall of the stomach is thickest near the antrum and thinnest near the AOH. The wall is also thinner at the greater curvature compared to the middle. An observational study of 141 resected sleeve specimens measuring fundus wall thickness with light microscopy showed that the male gender correlated with higher wall thickness. Leaks in this study occurred in females who had a thinner median wall thickness when compared to the nonleak group.
The staple line is the Achille's heel of the LSG. Over the years, surgeons have realized that subtle technical steps, when meticulously followed, have led to a decrease in the incidence of leaks. Creating a durable staple line requires “optimal stapling” [Figure 1] which includes selecting the appropriate stapler size and adhering to the “critical steps” while forging the sleeve right from the initiation up to the conclusion of the procedure. Critical steps to follow include the correct distance from the pylorus to initiate the staple line, the correct size of the bougie to calibrate the sleeve, additional technical measures while firing the stapler, the decision to reinforce the staple line, and finally, performing an intraoperative leak test (IOLT).
|Figure 1: Depiction of key components of Optimal Stapling. Begin the transection (blue double head arrow) 5 cm away from the pylorus (P). Use proper sized staples according to the thickness of tissues (green load near pylorus and blue load subsequently). Stay away from the gastroesophageal junction (GEJ, red double headed arrow). Calibrate the sleeve over a bougie (B) not less than 32 Fr in size. Apply steady traction while stapling to avoid spiralling of the sleeve (grey block arrows)|
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Proper cartridge selection is based on the fact that the thickness of the stomach wall varies, decreasing from pylorus to AOH. Closed stapler height of at least 2 mm should be used on thick stomach because they are designed to be stronger (wider diameter) and form longer leg lengths. Expert consensus asserts that it is not appropriate to use staples with a closed height less than that of 1.5 mm on any part of the sleeve gastrectomy. Considering the biphasic nature of human tissues, and taking into account that the phenomena of tissue creep, stress relaxation, and shear stress are dependent on one common factor – time, optimal stapling would consist of allowing adequate time for tissue compression and creep while not producing excessive tensile stress. This results in good apposition and negligent structural modifications with no long-term tissue disruption.
Distance from pylorus and bougie size
The distance of initiating the transection from the pylorus and the bougie size over which the sleeve is created have a bearing on the degree of weight loss as well as leak incidence as these factors affect the final size of gastric tube, the staple-line orientation and the intragastric pressure. To achieve a more sustained long-term weight loss, a trend toward using narrower bougies has evolved after reports of sleeve dilation causing weight to regain requiring “re-sleeve” gastrectomy resurfaced. Parikh et al. observed that the most widespread practice is of using bougie <40 Fr (overall mean: 38 Fr) and starting ≥5 cm from the pylorus. In their meta-analysis of 9991 LSG patients, it was observed that distance from the pylorus does not impact leak or weight loss and utilizing bougie size ≥40 Fr may decrease leak without significantly impacting weight loss up to 3 years. The International Sleeve Gastrectomy Expert Panel, in their practice guidelines, agreed that using a bougie of <32 Fr may increase the postoperative strictures. Their recommendation is to use a bougie size ≥40 Fr and begin the gastric transection 5–6 cm from the pylorus.
Certain technical measures need to be taken to ensure that consecutive stapling proceeds without any staple-line failure. Bunching of tissue at the crotch of the stapler must be avoided. The surgeon must watch for and remove the “migratory crotch staple” which usually occurs after the first firing as the blade catches a staple in the crossover area, the consequence of which can be the stapler locking when firing is attempted or creation of a wedge band bypass failure leading to a compromised staple line. Important to note is the necessity to keep a steady hand when firing the stapler while providing a continuous lateral traction over the stomach to avoid a twisted sleeve and affect tissue incorporation at the distal effector end. It is imperative to stay away from the GE junction at least 1–2 cm to avoid ischemic complications, avoid inadvertent stapling across the distal esophagus, and at the same time avoid leaving a significant residual fundus., Aggressive dissection in the vicinity of proximal posterior stomach should be avoided to prevent devascularization which may be associated with an increased risk of leak.
To strengthen the staple line, oversewing, absorbable synthetic buttressing, biologic cross-linked buttressing (Bovine pericardium), biologic noncross-linked buttressing (absorbable-porcine small intestinal submucosa), thrombin matrix, and fibrin glue, etc., have been suggested. Various clinical studies have sought to compare these staple-line reinforcement methods with mixed results [Table 2]. The international LSG consensus expert panel reported that reinforcement of LSG staple line is a valid option. It was also agreed by 100% of the panelists that reinforcement has a definite advantage in reducing staple-line bleed. At the beginning of the last decade, RCTs, and systematic review did not find any significant difference in the incidence of staple-line leak or bleed when different techniques of staple-line reinforcement were compared. A multi-center retrospective study in 2014 involving 1162 patients compared different techniques of reinforcement (oversewing, bovine pericardium, Biosyn polymer, absorbable polymer membrane, thrombin matrix, and no reinforcement) concluded that bovine pericardium significantly reduced staple-line leak. The study also found that reinforcement decreased the incidence of staple-line bleed. The advantage of bovine pericardium was also reported in a meta-analysis of 13627 patients where bovine pericardium was associated with decreased incidence of staple-line leak and bleed. RCTs comparing oversewing of staple line to other modalities have reported varied results. Two RCTs, reported that oversewing is an unrewarding act which prolongs operating time with no advantage in terms of decreasing staple-line leak or bleed. Comparing oversewing with no reinforcement, one RCT reported decreased incidence of staple-line bleed, while the other reported a decrease in staple-line leak when some form of oversewing was utilized. Gagner published systematic reviews in 2014 and 2020 comparing different techniques of staple-line reinforcement. The first review in 2014 included 8729 patients and showed that the use of APM resulted in decreased incidence of leak when compared to oversewing, bovine pericardial strips, or no reinforcement. Similar results were reported in 2020 which included 40,653 patients and additionally included the use of tissue sealant as a means to reinforce the staple line.
Intraoperative leak test
The IOLT at the conclusion of the procedure is a widespread practice, but studies have shown that it has a low sensitivity, thus questioning its utility given the fact that most leaks develop after surgery. However, it has been contended that the purpose is to inspect the newly created staple line and detect leaks caused by the rare technical failure or staple malfunction at that moment and thus avoid the severe consequence of a missed leak., However, a negative IOLT in no way precludes the possibility of a subsequent staple-line leak. Considering these facts, the recommendation, albeit with a low level of evidence, is to perform an IOLT.
| Conclusion|| |
Contrary to the popular belief, LSG is an intricate procedure wherein the minute technical details need to be comprehended and followed for a successful outcome. Starting from the proper patient selection, understanding the risk factors and pathophysiology of leaks, and abiding by the subtle technical factors, a successful outcome ensues. Based on tissue thickness, staple size less than that of 1.5 mm should not be used on the stomach (level of evidence: 1). To balance the risk of postoperative stricture or leak and concomitantly allowing for an acceptable weight loss, stapling should be initiated at least 5 cm from pylorus (level of evidence: 2-3) and calibrated on a bougie that should not be <32 Fr size (level of evidence: 1). Reinforcing the staple line definitely reduces the incidence of hemorrhage, and current evidence indicates the incidence of leak also (level of evidence: 1).,, Performing a leak test, though offers less sensitivity to predict a leak, does help in detecting the immediate mechanical failure of staple line (level of evidence: 4)., We believe that appreciating these concerns and following the published recommendations should help one to accomplish a safe and successful sleeve gastrectomy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]